this is a blog for patients and their families to read and enjoy. It's a series of stories about patients. I'm trying to educate the layman about medicine so that they can empower themselves to acquire the best medical care available to them.

Thursday, January 2, 2014

I
was working at a rural health clinic in the Eastern hills of Texas when one day
a Hispanic female came into be seen.She
was in her 20s, and I found out that she was trying to help support her family
of two young kids who’s husband was usually gone being a long haul truck
driver.

I
knocked on the exam room door and went into introduce myself to a new patient
named Maria.

“Hi,
I’m Sharon, I’m the PA who works at this clinic.How can I help you?”

Through
her sister that she used as a Spanish translator, Maria responded, “I’ve got
pain and numbness in both of my hands, it comes and goes and I need help.”

“Ok,
what do you do day to day?”

“Well
I take care of my two young children who are not in school yet, try to keep my
house clean, feed my kids and then I work 40 hours a week over at the slaughter
house which processes fresh chicken for our grocery stores.”

“What
exactly do you do at the slaughter house?”

“I
work the line, I take the sliced chicken and make the final cuts into it so that
it ends up in nine pieces, which is then packaged and sent out.So I use my hands all the time.”

“What
about at home?”

“My
hands are usually numb when I get home, so I end up trying to shake them awake
several times every night, which doesn’t work.By the time I go to bed I usually have pain in one or both of my hands
and have to take some Tylenol so as to be able to sleep.”

Risk Factors for
Carpel Tunnel Syndrome:

--repetitive actions
of the hand or wrist

--sustained hand or
arm positions

--sleep

Usual Symptoms:

--dull, aching
discomfort in the hand, wrist or forearm

--numbness in the
hand, usually in the first three fingers, sometimes involves the fourth finger
(which is the area that the median nerve serves)

--weakness in the
hand, clumsiness with grasping objects

--sometimes it helps
when the patient shakes their hands, this can sometimes decrease the tingling
or pain temporarily

“Is
there a spouse in the picture?”

“Yes,
but he’s gone the majority of the time.He works as a long haul truck driver.He’s only home every few days every other week.”

“Hmm,
okay.”

“So
let me ask you do you take any medications on a regular basis or are you
allergic to any medications?”

Through
her translating sister, Maria responded, “No, to both of your questions.”

“Alright,
have you had any prior surgeries?”

“No.”

“Okay,
well then let me take a look at your hands and we’ll go from there.”With that I approached her sitting on the
exam table and picked up her left hand and started to palpate it to assess
whether she had any abnormal growths or potential hand fractures.Then I asked her, “where exactly is your
numbness and/or pain in your hands when it shows up?”

She
pointed to her first three fingers on both hands and then the medial side
(inside edge) of her wrists.

"Do
you have any tingling or numbness above your wrists?”

“Every
once in a while, I’ll get some tingling up my forearms that doesn’t last very
long.”

“Ok.
Let me see your other hand for a moment.”Maria handed me her right hand and I palpated it to make sure there
wasn’t any abnormality with it.Once I
had determined that she didn’t have any obvious problem with her hands I asked
her to put her hands in a totally flexed position (do an internet search for Phalen's test to see pictures of this) that put
pressure on her wrists.I asked her to
hold that position for 60 seconds.Maria
was only able to hold the position for 20 seconds before she said her hands had
gone numb again.

Then I asked Maria to hold out her
hands and I tapped on her wrist (do an internet search for Tinel
test, carpel tunnel syndrome to see how to do this maneuver).Maria had tingling pain referred
down into her hands when I did this, which is a positive test.

So I knew that Maria had what is
called ‘carpel tunnel syndrome’ in both of her hands.

“Maria, you have what is called
‘carpel tunnel syndrome.This means that
you have tendon swelling in the carpel tunnel area that is pressing down on the
nerve that serves your hand and gives it sensation and motor movement.Your carpel tunnel is right here in the
center of your wrist and it is a small round hole through which many of the
tendons that start at your elbow come down into your hand.This is also where the big nerve to your
hand, called the median nerve comes down into your hand.Your tendon(s) are swollen because of all of
the repetitive work you do cutting and packaging chicken.”

“So, what do I do about it?” asked
Maria.

“Well, usually we can treat it with
some Motrin and your wearing wrist braces which will hold your hands/wrist in
the most relaxed position for your hands.You should notice an improvement in your symptoms after a few days, but
definitely by the time you come back to see me in two weeks.”

So where do I get the wrist
braces?”

“We’ve got them here in the clinic,
I’ll go get them and show you how to wear them.”

With that I left the exam room and
quickly found the wrist splints for both of her hands in our supply cabinet and
came back in and showed her how to wear the splints.I explained to her that she needed to wear
them at night and take prescriptive dose Motrin three times a day.I told her to make a return appointment to
see me in two weeks, which she did.

Two weeks later she returned to
clinic and her symptoms were almost gone, so I advised her to continue to wear
the splints at night and to stop the Motrin.

When I saw Maria in clinic more than
10 years ago it was common practice to use a non-steroidal medication such as
Motrin along with the wrist splints which keep the patient’s hands in the most
relaxed position possible so as to allow the swelling of their tendon(s) coming
through the carpel tunnel area to normalize in size again.Nowadays there is evidence that Motrin or
other non-steroids don’t work and are not recommended.Instead what is recommended is to use the
wrist splints along with systemic steroids, such as prednisone.

If
the wrist splints/prednisone doesn’t work then patients are referred over to a
hand surgeon who goes into the carpel tunnel area surgically and enlarges the
area of bone involved so that the median nerve, hand tendons have a larger area
to travel through on their way to the patient’s hand.

About Me

I'm a physician assistant with more 20+ years (and counting) of clinical medicine experience. I'm writing this blog for you, a potential patient, or for one of your family members, in order to empower you to acquire the best medical care available.
Please do not look upon these stories as direct medical advice. If you have any questions or think you need to change your medical treatment, please discuss this with your own physician.